Skip to main content
SpringerLink
Log in

Lactated Ringers Does Not Reduce SIRS in Acute Pancreatitis Compared to Normal Saline: An Updated Meta-Analysis

  • Original Article
  • Published:
Digestive Diseases and Sciences Aims and scope Submit manuscript

Abstract

Background

We aimed to compare outcomes according to a Lactated Ringers (LR) versus Normal Saline (NS)-based strategy for acute pancreatitis.

Methods

A database search through November 2020 was done to identify studies comparing LR to NS for fluid rehydration in AP. The primary endpoint was systemic inflammatory response syndrome (SIRS) at 24 h. Mantel–Haenszel pooled odds ratios (OR) and 95% confidence intervals were constructed using a random effects model. Heterogeneity was assessed using the I2 statistic. Publication bias was assessed using funnel plots.

Results

Six studies were included totaling 549 patients. No difference in the odds of developing SIRS was noted at 24 h (pooled OR 0.59, 95% CI 0.22–1.62, P = 0.31) between LR and NS. I2 indices showed low heterogeneity between the groups, and a funnel plot showed no obvious publication bias. There was no difference between LR and NS found for SIRS at 48 and 72 h, mortality, and other secondary outcomes. LR was associated with a decreased need for ICU admission.

Conclusions

This updated meta-analysis does not support the previously published finding that the use of LR (rather than NS) leads to a statistically significant decreased odds of SIRS in acute pancreatitis.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Peery AF, Crocket SD, Murphy CC et al. Burden and cost of gastrointestinal, liver and pancreatic diseases in the United States: update 2018. Gastroenterology 2019;156:254-272.e11.

    PubMed  Google Scholar 

  2. Banks PA, Bollen TL, Dervenis C et al. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013;62:102–111.

    PubMed  Google Scholar 

  3. Sternby H, Bolado F, Canaval-Zuleta HJ, Marra-Lopez C et al. Determinants of severity in acute pancreatitis: a nation-wide multicenter prospective cohort study. Ann Surg 2019;270:348–355.

    PubMed  Google Scholar 

  4. Garg PK, Singh VP. Organ failure due to systemic injury in acute pancreatitis. Gastroenterology 2019;156:2008–2023.

    PubMed  Google Scholar 

  5. Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology 2013;13:e1.

    Google Scholar 

  6. Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, Parks RW. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg 2006;93:738–744.

    CAS  PubMed  Google Scholar 

  7. Singh VK, Wu BU, Bollen TL et al. Early systemic inflammatory response syndrome is associated with severe acute pancreatitis. Clin Gastroenterol Hepatol 2009;7:1247–1251.

    PubMed  Google Scholar 

  8. Garcia-Rayado G, Cardenas-Jaen K, de-Madaria E. Towards evidence-based and personalized care of acute pancreatitis. United Eur Gastroenterol J 2020;8:403–409.

    Google Scholar 

  9. Wu BU, Johannes RS, Sun X, Conwell DL, Banks PA. Early changes in blood urea nitrogen predict mortality in acute pancreatitis. Gastroenterology 2009;137:129–135.

    CAS  PubMed  Google Scholar 

  10. Gardner TB, Vege SS, Pearson RK, Chari ST. Fluid resuscitation in acute pancreatitis. Clin Gastroenterol Hepatol 2008;6:1070–1076.

    PubMed  Google Scholar 

  11. Vege SS, DiMagno MJ, Forsmark CE, Martel M, Barkun AN. Initial medical treatment of acute pancreatitis: American gastroenterological association institute technical review. Gastroenterology 2018;154:1103–1139.

    PubMed  Google Scholar 

  12. Haydock MD, Mittal A, Wilms HR, Phillips A, Petrov MS, Windsor JA. Fluid therapy in acute pancreatitis: anybody’s guess. Ann Surg 2013;257:182–188.

    PubMed  Google Scholar 

  13. de-Madaria E, Garg PK. Fluid therapy in acute pancreatitis—aggressive or adequate? Time for reappraisal. Pancreatology 2014;14:433–435.

    PubMed  Google Scholar 

  14. Iqbal U, Anwar H, Scribani M. Ringer’s lactate versus normal saline in acute pancreatitis: a systematic review and meta-analysis. J Dig Dis 2018;19:335–341. https://doi.org/10.1111/1751-2980.12606

    Article  PubMed  Google Scholar 

  15. Lee A, Ko C, Buitrago C, Hiramoto B, HIIson L, Buxbaum J. Lactated ringers vs normal saline resuscitation for mild acute pancreatitis: a randomized trial. Gastroenterology 2021;160:955.

    PubMed  Google Scholar 

  16. Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the prisma statement. PLoS Med 2009;6:e1000097.

    PubMed  PubMed Central  Google Scholar 

  17. Wells G, Shea B, O’Connel D, et al. Ottawa Hospital Research Institute. Published 2019. Accessed November 15, 2020. http://ohri.ca/programs/clinical_epidemiology/oxford.asp.

  18. Jadad AR, Moore RA, Carrol D et al. Assessing the quality of reports of randomized clinical trials: Is blinding necessary? Control Clin Trials 1996;17:1–12.

    CAS  PubMed  Google Scholar 

  19. American College of Chest Physicians, Society of Critical Care Medicine. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions of sepsis and organ failure and guidelines for the use of innovative therapies in sepsis – PubMed. Crit Care Med. 1992;20:864–874. Accessed February 8, 2021. https://pubmed.ncbi.nlm.nih.gov/1597042/.

  20. de-Madaria E, Herrera-Marante I, Gonzalez-Camacho V et al. Fluid resuscitation with lactated Ringer’s solution vs normal saline in acute pancreatitis: a triple-blind, randomized, controlled trial. United Eur Gastroenterol J 2018;6:63–72.

    Google Scholar 

  21. Wu BU, Hwang JQ, Gardner TH et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol 2011;9:710–717.

    PubMed  Google Scholar 

  22. Choosakul S, Harinwan K, Chirapongsathorn S et al. Comparison of normal saline versus lactated Ringer’s solution for fluid resuscitation in patients with mild acute pancreatitis. A randomized controlled trial. Pancreatology 2018;18:507–512.

    CAS  PubMed  Google Scholar 

  23. Aboelsoud MM, Siddique O, Morales A, Seol Y, Al-Qadi MO. Fluid choice matters in critically-ill patients with acute pancreatitis: lactated ringer’s versus isotonic saline. R I Med J 2013;2016:39–42.

    Google Scholar 

  24. Lipinski M, Rydzewska-Rosolowska A, Rydzewski A, Rydzewska G. Fluid resuscitation in acute pancreatitis: normal saline or lactated Ringer’s solution? World J Gastroenterol 2015;21:9367–9372.

    CAS  PubMed  PubMed Central  Google Scholar 

  25. Bassi D, Kollias N, Fernandez-del Castillo C, Foitzik T, Warshaw AL, Rattner DW. Impairment of pancreatic microcirculation correlates with the severity of acute experimental pancreatitis. J Am Coll Surg 1994;179:257–263.

    CAS  PubMed  Google Scholar 

  26. de-Madaria E, Banks PA, Moya-Hoyo N, Wu BU, Rey-Riveiro M, Acevedo-Piedra NG. Early factors associated with fluid sequestration and outcomes of patients with acute pancreatitis. Clin Gastroenterol Hepatol 2014;12:997–1002.

    PubMed  Google Scholar 

  27. Kinnala PJ, Kuttila KT, Gronroos JM, Havia TV, Nevalainen TJ, Niinikoski JH. Pancreatic tissue perfusion in experimental acute pancreatitis. Eur J Surg 2001;167:689–694.

    CAS  PubMed  Google Scholar 

  28. D’Haese J, Werner J. Translational research for acute pancreatitis—which results have really influenced our therapy? Visc Med 2018;34:436–438.

    PubMed  PubMed Central  Google Scholar 

  29. Radadiya D, Devani K, Arora S et al. Peri-procedural aggressive hydration for post endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis prophylaxis: meta-analysis of randomized controlled trials. Pancreatology 2019;19:819–827.

    PubMed  Google Scholar 

  30. Buter A, Imrie CW, Carter CR, Evans S, McKay CJ. Dynamic nature of early organ dysfunction determines outcome in acute pancreatitis. Br J Surg 2002;89:298–302.

    CAS  PubMed  Google Scholar 

  31. Johnson CD, Abu-Hilal M. Persistent organ failure during the first week as a marker of fatal outcome in acute pancreatitis. Gut 2004;53:1340–1344.

    CAS  PubMed  PubMed Central  Google Scholar 

  32. Yang CJ, Chne J, Phillips ARJ, Windsor JA, Petrov MS. Predictors of severe and critical acute pancreatitis: a systematic review. Dig Liver Dis 2014;46:446–451.

    PubMed  Google Scholar 

  33. Rodriguez JR, Razo AO, Targarona J, Thayer SP, Rattner DW, Warshaw AL. Debdridement and closed packing for sterile or infected necrotizing pancreatitis: insights into indications and outcomes in 167 patients. Ann Surg 2008;247:294–299.

    PubMed  Google Scholar 

  34. Rattner DW, Legermate DA, Lee MJ, Mueller PR, Warshaw AL. Early surgical debridement of symptomatic pancreatic necrosis is beneficial irrespective of infection. Am J Surg 1992;163:105–110.

    CAS  PubMed  Google Scholar 

  35. Bhoomagoud M, Jung T, Atladottir J et al. Reducing extracellular pH sensitizes the acinar cell to secreatogogue-induced pancreatitis responses in rats. Gastroenterology 2009;137:1083–1092.

    CAS  PubMed  Google Scholar 

  36. Noble MD, Romac J, Vigna SR, Liddle RA. A pH-sensitive, neurogenic pathway mediates disease severity in a model of post-ERCP pancreatitis. Gut 2008;57:1566–1571.

    CAS  PubMed  Google Scholar 

  37. Iraporda C, Errea A, Romanin DE, Cayet D, Pereyra E, Pignataro O. Lactate and short chain fatty acids produced by microbial fermentation downregulate proinflammatory responses in intestinal epithelial cells and myeloid cells. Immunobiology 2015;220:1161–1169.

    CAS  PubMed  Google Scholar 

  38. Khatua B, Yaron JR, El-Kurdi B, Kostenko S, Papachristou GI, Singh VP. Ringer’s lactate prevents early organ failure by providing extracellular calcium. J Clin Med 2020;9:263.

    CAS  PubMed Central  Google Scholar 

  39. Gheorghe C, Dadu R, Blot C et al. Hyperchloremic metabolic acidosis following resuscitation of shock. Chest 2010;138:1521–1522. https://doi.org/10.1378/chest.10-1458.

    Article  PubMed  Google Scholar 

  40. Krajewski ML, Raghunathan K, Paluszkiewicz SM, Schermer CR, Shaw AD. Meta-analysis of high- versus low-chloride content in perioperative and critical care fluid resuscitation. Br J Surg 2015;102:24–36.

    CAS  PubMed  Google Scholar 

  41. Rajamaki K, Nordstrom T, Nurmi K et al. Extracellular acidosis is a novel danger signal alerting innate immunity via the NLRP3 inflammasome. J Biol Chem 2013;288:13410–13419.

    CAS  PubMed  PubMed Central  Google Scholar 

  42. Hadimioglu N, Saadawy I, Saglam T, Ertug Z, Dinckan A. The effect of different crystalloid solutions on acid-base balance and early kidney function after kidney transplantation. Anesth Analg 2008;107:264–269.

    CAS  PubMed  Google Scholar 

  43. Kellum JA, Song M, Li J. Science review: extracellular acidosis and the immune response: clinical and physiologic implications. Crit Care 2004;8:331–336.

    PubMed  PubMed Central  Google Scholar 

  44. Raghunathan K, Shaw A, Nathanson B et al. Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis*. Crit Care Med 2014;42:1585–1591.

    CAS  PubMed  Google Scholar 

  45. Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012;308:1566–1572.

    CAS  PubMed  Google Scholar 

Download references

Funding

There was no grant support involved in the conduction, research, or writing of this manuscript. There authors disclose no financial arrangements related to the research or assistance with manuscript preparation.

Author information

Authors and Affiliations

  1. Department of Medicine, University of Miami, Miami, FL, USA

    Shyam Vedantam

  2. Department of Hepatology & HPB Medicine, University Hospital Southampton NHS Foundation Trust, Southampton, UK

    Nadeem Tehami

  3. Gastroenterology Department, Alicante University General Hospital, ISABIAL, Alicante, Spain

    Enrique de-Madaria

  4. Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami, 1120 NW 14th St, Clinical Research Building, Suite 11145 (D-49), Miami, FL, 33136, USA

    Jodie A. Barkin & Sunil Amin

Authors
  1. Shyam Vedantam
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nadeem Tehami
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Enrique de-Madaria
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Jodie A. Barkin
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Sunil Amin
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sunil Amin.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest for this article.

Informed consent

For this type of study (retrospective meta-analysis), formal consent is not required.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary Figure 1. Forrest plot of LR vs NS for moderate-severe pancreatitis incidence. Pooled OR 0.86, 95% CI 0.40–1.87, P = 0.71.

Supplementary file 1 (JPG 50 KB)

Supplementary Figure 2. Forrest plot of LR versus NS for organ failure incidence. Pooled OR 0.69, 95% CI 0.29–1.63, P = 0.40.

Supplementary file 2 (JPG 49 KB)

Supplementary Figure 3. Forrest plot of LR versus NS for local complication incidence. Pooled OR 0.48, 95% CI 0.20–1.16, P= 0.10.

Supplementary file 3 (JPG 45 KB)

Supplementary Figure 4. Forrest plot of LR versus NS for incidence of pancreatic necrosis. Pooled OR 0.65, 95% CI 0.23–1.81, P= 0.41.

Supplementary file 4 (JPG 56 KB)

Supplementary Figure 5. Forrest plot of LR versus NS for need for invasive treatment. Pooled OR 0.66, 95% CI 0.08–5.61, P= 0.70.

Supplementary file 5 (JPG 47 KB)

Supplementary Figure 6. Forrest plot of LR versus NS for need for nutritional support. Pooled OR 1.26, 95% CI 0.08–20.45, P = 0.87.

Supplementary file 6 (JPG 47 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Vedantam, S., Tehami, N., de-Madaria, E. et al. Lactated Ringers Does Not Reduce SIRS in Acute Pancreatitis Compared to Normal Saline: An Updated Meta-Analysis. Dig Dis Sci 67, 3265–3274 (2022). https://doi.org/10.1007/s10620-021-07153-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10620-021-07153-5

Keywords

Search

Navigation